I CE article _ bioceramic technology

A review of bioceramic
technology in endodontics
Authors_ Drs Ken Koch, Dennis Brave & Allen Ali Nasseh, USA

_ce credit

roots

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Fig. 1_The particle size of BC Sealer

is so fine (less than two microns),
it can actually be delivered with
a 0.012 capillary tip. (Photos/
Provided by Ken Koch, DMD)

Fig. 1

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_Since bioceramic technology was introduced

to endodontics, the response has been exceptional. As
more and more practitioners have thought through
the process, they have been able to see not only the
clear benefits of this technology in endodontics, but
they are now asking how this technology can be
applied to other aspects of dentistry. The application
of bioceramic technology has not only changed
endodontics both surgically and non surgically, it has
also begun to change the way we treatment plan our
patients. As a result of bioceramic technology, we now
have the ability to save more teeth in a predictable
fashion, while, in addition, improving their long-term

prognosis. The option of saving the natural dentition is now back on the table.
However, before we investigate specific techniques, we must first ask ourselves is, What are bioceramics? Bioceramics are ceramic materials specifically designed for use in medicine and dentistry. They
include alumina and zirconia, bioactive glass, glass
ceramics, coatings and composites, hydroxyapatite
and resorbable calcium phosphates.1, 2
There are numerous bioceramics currently in use
in both dentistry and medicine, although more so in
medicine. Alumina and zirconia are among the bioinert ceramics used for prosthetic devices. Bioactive
glasses and glass ceramics are available for use in
dentistry under various trade names. Additionally,
porous ceramics such as calcium phosphate-based
materials have been used for filling bone defects. Even
some basic calcium silicates such as ProRoot MTA
(DENTSPLY) have been used in dentistry as root repair
materials and for apical retrofills.
Although employed in both medical and dental
applications, it is important to understand the specific advantages of bioceramics in dentistry and why
they have become so popular. Clearly the first answer
is related to physical properties. Bioceramics are
exceedingly biocompatible, nontoxic, do not shrink,
and are chemically stable within the biological environment. Additionally, and this is very important in
endodontics, bioceramics will not result in a significant inflammatory response if an over fill occurs
during the obturation process or in a root repair. A
further advantage of the material itself is its ability
(during the setting process) to form hydroxyapatite
and ultimately create a bond between dentin and the
filling material. A significant component of improving this adaptation to the canal wall is the hydrophilic
nature of the material. In essence, it is a bonded
restoration. However, to fully appreciate the properties associated with the use of bioceramic technology,
we must understand the hydration reactions involved
in the setting of the material.

CE article _ bioceramic technology

_EndoSequence BC sealer setting reactions

The calcium silicates in the powder hydrate to
produce a calcium silicate hydrate gel and calcium
hydroxide. The calcium hydroxide reacts with the
phosphate ions to precipitate hydroxyapatite and
water. The water continues to react with the calcium silicates to precipitate additional gel-like calcium silicate hydrate. The water supplied through
this reaction is an important factor in controlling
the hydration rate and the setting time as following:
The hydration reactions (A, B) of calcium silicates
can be approximated as follows:
2[3CaO SiO2] + 6H2O 3CaO 2SiO2 3H2O + 3Ca(OH)2
2[2CaO SiO2] + 4H2O 3CaO 2SiO2 3H2O + Ca(OH)2

(A)
(B)

The precipitation reaction (C) of calcium phosphate apatite is as follows:

7Ca(OH)2 + 3Ca(H2PO4 )2 Ca10(PO4 )6 (OH)2 + 12H2O

(C)

For clinical purposes (in endodontics), the advantages of a premixed sealer should be obvious. In
addition to a significant saving of time and convenience, one of the major issues associated with the
mixing of any cement, or sealer, is an insufficient and
non-homogenous mix. Such a mix may ultimately
compromise the benefits associated with the material. Keeping this in mind, a new premixed bioceramic
sealer has been designed that hardens only when
exposed to a moist environment, such as that produced by the dentinal tubules.3
But, what is it specifically about bioceramics that
make them so well suited to act as an endodontic
sealer? From our perspective as endodontists, some
of the advantages are: high pH (12.8) during the initial 24 hours of the setting process (which is strongly
anti-bacterial); they are hydrophilic, not hydrophobic; they have enhanced biocompatibility; they do
not shrink or resorb (which is critical for a sealerbased technique); they have excellent sealing ability;
they set quickly (three to four hours); and they are
easy to use (particle size is so small it can be used in a
syringe).
The introduction of a bioceramic sealer (EndoSequence BC Sealer, Brasseler) allows us, for the first
time, to take advantage of all the benefits associated
with bioceramics but to not limit its use to merely
root repairs and apical retrofills. This is only possible
because of recent nanotechnology developments;
the particle size of BC Sealer is so fine (less than two
microns), it can actually be delivered with a 0.012
capillary tip (Fig. 1).

This material has been specifically designed as a

non-toxic calcium silicate cement that is easy to use
as an endodontic sealer. This is a key point. In addition
to its excellent physical properties, the purpose of BC
Sealer is to improve the convenience and delivery
method of an excellent root canal sealer, while simultaneously taking advantage of its bioactive characteristics (it utilizes the water inherent in the dentinal
tubules to drive the hydration reaction of the material, thereby shortening the setting time).
As we know, dentin is composed of approximately
20 per cent (by volume) water, and it is this water that
initiates the setting of the material and ultimately
results in the formation of hydroxyapatite.4 Therefore,
if any residual moisture remains in the canal after
drying, it will not adversely affect the seal established
by the bioceramic cement. This is very important in
obturation and is a major improvement over previous
sealers. Furthermore, its hydrophilicity, small particle
size and chemical bonding to the canal walls also
contribute to its excellent hydraulics. But there is
another aspect to sealer hydraulics. That is the shape
of the prepared canal itself.
Actually, it all begins with the file. To be more
specific, it all begins with the specific preparation
created by the filea constant taper preparation.
When using the EndoSequence technique, we can
create either a 0.04 constant taper preparation or a
0.06 taper. The real key is the constant taper preparation, because when accomplished it now gives us
the ability to create predictable, reproducible shapes.
A variable taper preparation is not recommended
because its lack of shaping predictability (and its corresponding lack of reproducibility) will lead to a less
than ideal master cone fit. This lack of endodontic
synchronicity is why all variable taper preparations
are associated with the overly expensive and more
time consuming thermoplastic techniques.

Fig. 2a_This image shows the

excellent adaption of the bioceramic
sealer (and gutta-percha) to the true
shape of the prepared canal.

Fig. 2a

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I CE article _ bioceramic technology

Knowing in advance what the final shape (constant
taper preparation) will be is a tremendous advantage
in creating superior hydraulics. Then add in the feature
of laser verified paper points and gutta-percha cones,
and we now start to develop a system where everything matches (true endodontic synchronicity).
This concept of having everything match is so important because it allows us, for the first time, to perform rotary endodontics in a truly conservative fashion and to be able to use a hydraulic condensation
technique. Furthermore, when used in conjunction
with the EndoSequence filing system, this becomes a
synchronized hydraulic condensation technique. This

est reported value was in Group IV, which employed

ActiV GP sealer in combination with regular guttapercha cones. The conclusion of this study was that
employing a bioceramic sealer (such as BC Sealer) is
very promising in terms of strengthening the residual
root and increasing the in vitro fracture resistance of
endodontically treated teeth. This is a very significant
finding, especially regarding the long term retention
of an endodontically treated tooth.
In this particular study, the bioceramic sealer performed best when combined with ActiV GP cones. In
fact, bonding will occur between the bioceramic sealer
and the ceramic particles in the ActiV GP cones as
well as to the bioceramic particles present in the new
bioceramic coated cones (BC cones). The technique of
achieving a true bond between the root canal wall and
the master cone (as a result of creating endodontic
synchronicity and advanced material science) is
known as synchronized hydraulic condensation.

_Synchronized hydraulic condensation

Fig. 2b
Fig. 2b_A composite image
demonstrating the true
excellence of the technique.

has tremendous implications for the tooth as evidenced by a recent study published in the Journal of
Endodontics.5 The purpose of this study was to evaluate and compare the fracture resistance of roots obturated with various contemporary-filling systems. The
investigators (Ghoneim, et. al.) instrumented 40 single-canal premolars using 0.06 taper EndoSequence
files. The teeth were then obturated using four different techniques. Group I used a bioceramic sealer iRoot
SP (IRoot SP is BC Sealer in Europe) in combination with
ActiV GP cones (Brasseler) while Group II used the
bioceramic sealer with regular gutta-percha. Group III
utilized ActiV GP sealer plus ActiV GP cones and Group
IV employed ActiV G sealer with conventional guttapercha cones. All four groups were obturated using a
single cone technique. Ten teeth were left unprepared
and these acted as a negative control for the study.
Following preparation and obturation, all the teeth
were embedded in acrylic molds and then subjected to
a fracture resistance test in which a compressive load
(0.5mm/min) was applied until fracture. Subsequently,
all data was statistically analyzed using the analysis of
variance model and the Turkey post hoc test.
Then results generated were quite remarkable. It
was demonstrated that the significantly highest fracture resistance was recorded for both the negative
control and Group I (bioceramic sealer /Activ GP cone)
with no statistical difference between them. The low-

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The technique with this material is quite straightforward. Simply remove the syringe cap from the
EndoSequence BC Sealer syringe. Then attach an Intra
Canal Tip of your choice to the hub of the syringe. The
Intra Canal Tip is flexible and can be bent to facilitate
access to the root canal. Also, because the particle size
has been milled to such a fine size (less than 2 microns),
a capillary tip (such as a 0.012) can be used to place
the sealer.
Following this procedure, insert the tip of the syringe into the canal no deeper than the coronal one
third. Slowly and smoothly dispense a small amount
of EndoSequence BC Sealer into the root canal. Then
remove the disposable tip from the syringe and proceed to coat the master gutta-percha cone with a thin
layer of sealer. After the cone has been lightly coated,
slowly insert it into the canal all the way to the final
working length. The synchronized master gutta-percha cone will carry sufficient material to seal the apex.6
The precise fit of the EndoSequence gutta-percha
master cone (in combination with a constant taper
preparation) creates excellent hydraulics and, for
that reason, it is recommended that the practitioner
use only a small amount of sealer. Furthermore, as
with all obturation techniques, it is important to insert the master cone slowly to its final working
length. Moreover, the EndoSequence System is now
available with bioceramic coated gutta-percha
cones. So in essence, what we can now achieve with
this technique is a chemical bond to the canal wall,
as a result of the hydroxyapatite that is created during the setting reaction of the bioceramic material
and we also have a chemical bond between the

I CE article _ bioceramic technology

_Materials and methods

Fig. 3a

Sixteen recently extracted human molars were

mounted on individual stubs and underwent an initial high spatial resolution CT scan prior to any treatment. Following biomechanical crown-down canal
preparation to an apical matrix of 35/0.04 and ultrasonic irrigation with 6 per cent sodium hypochlorite,
each sample was scanned a second time. Obturation
was completed using a single matched gutta-percha
cone and EndoSequence BC sealer. The coronal 4mm
of the gutta-percha was thermo-softened and compacted vertically. Subsequent to canal obturation, a
third scan was made.

Fig. 3b

Fig. 3c

Fig. 3d

Figs. 3a5c_Cases treated with

bioceramics. (Clinical X-rays/
Provided by Allen Ali Nasseh,
DDS, MMSc)

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ceramic particles in the sealer and the ceramic particles on the bioceramic coated cone.

Scanning of the specimens was performed (Actis

150/130, Varian Medical Systems) with a 180-degree
rotation around the vertical axis and a single rotation
step of 0.9 degree with a cross-sectional pixel size of
approximately 24m. All three backscatter projections
were aligned post-processing with sub-voxel accuracy at 92 per cent CI in VG Studio Max 2.1 (Volume
Graphics GmbH) and manipulated to create regions of
interest for each of the scans.

_Results
Think about what we have just accomplished. We
are now doing root canals in a manner that truly is
easier, faster and better. As further evidence of this
technique, we asked Dr Adam Lloyd, the chairman of
the Department of Endodontics at the University of
Tennessee, to share the results of a study recently
conducted at the University of Tennessee.7

Analysis of volume occupied by sealer in relation to

total original canal volumes was found to be extremely
high with a mean of 97 per cent 2.8, much higher than
reported previously using studies on canal surface
area occupancy of material, with 75 per cent of samples occupied at the 95 per cent level (Figs. 2a, 2b).

Fig. 4a

Fig. 4b

Fig. 4c

Fig. 5a

Fig. 5b

Fig. 5c

CE article _ bioceramic technology

While the properties associated with bioceramics

make them very attractive to dentistry, in general,
what would be their specific advantage if used as an
endodontic sealer? From our perspective as endodontists, some of the advantages are: enhanced biocompatibility, possible increased strength of the root
following obturation, high pH (12.8) during the setting process which is strongly anti-bacterial, sealing
ability related to its hydophilicity, and ease of use.8
Furthermore, the bioceramic sealer does not shrink
upon setting (it actually expands 0.002 per cent) and
once it is fully set, the material will not resorb.

Fig. 6a

Fig. 6b

Fig. 6c

Fig. 6d

The cases pictured in Figs. 3a through 5c demonstrate the excellence of this technique.

_Retreatment of bioceramics
Bioceramic sealer cases are definitely retreatable
yet the issue of retreating these cases (and all the
associated misinformation) is not unlike that of glass
ionomer. Historically there has been confusion about
retreating glass ionomer endodontic cases (glass
ionomer sealer is definitely retreatable when used as
a sealer) and, similarly, there has been confusion
concerning the retreatability of bioceramics.8 The key
is using bioceramics as a sealer, not as a complete
filler. This is why endodontic synchronicity is so important and again, why the use of constant tapers
makes so much sense (it minimizes the amount of
endodontic sealer thereby facilitating retreatment).
The technique itself is relatively straightforward.
The key in retreating bioceramic cases is to use an
ultrasonic with a copious amount of water. This is
particularly important at the start of the procedure in
the coronal third of the tooth. Work the ultrasonic
(with lots of water) down the canal to approximately
half its length. At this point, add a solvent to the canal
(chloroform or xylol) and switch over to an EndoSequence file (#30 or 35/0.04 taper) run at an increased rate of speed (1,000RPM). Proceed with this
file, all the way to the working length, using solvent
when indicated. An alternative is to use hand files for
the final 2-3mm and then follow the gutta-percha
removal with a rotary file to ensure synchronicity.
The case pictured in Figs. 6a and 6b demonstrates
the retreatment of BC Sealer.

_Bioceramics as a root repair material

We are all familiar with the success of MTA (mineral trioxide aggregate) as a root repair and apico
retrofilling material. Furthermore, we realize that
because MTA is a modified Portland cement, it has
some limitations in terms of handling characteristics.
It does not come premixed (and therefore must be
mixed by hand), is difficult to use on retrofills, and has
such a large particle size that it cannot be extruded
through a small syringe. Yet it has a number of favorable characteristics including a pH of 12.5, which is
significantly anti-bacterial. However, in lieu of a
Portand cement-based material, we now have available a medical grade bioceramic repair material.

Figs. 6a6d_A case demonstrating

retreatment of BC Sealer. (Clinical Xrays/Provided by Allen Ali Nasseh,
DDS MMSc)

This new repair material is, in fact, the EndoSequence Root Repair material, which comes either
premixed in a syringe (just like BC Sealer) or as a premixed putty (Fig. 7). This is a tremendous help not just
in terms of assuring a proper mix but also in terms of
ease of use. We now have a root repair material with
an easy and efficient delivery system. This is a key
development and a serious upgrade. This allows many
clinicians, not just specialists, to take advantage of
its properties.
Fig. 7_EndoSequence Root Repair
Material. (Image courtesy of Real
World Endo)
Fig. 8_A section of material ready for
delievery.

Fig. 7

Fig. 8

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I CE article _ bioceramic technology

Fig. 9a

Fig. 9b

Figs. 9a10c_Cases demonstrate

healing and bone fill in less than six
months. (Clinical X-rays/Provided by
Allen Ali Nasseh, DDS MMSc)

Fig. 9c

EndoSequence Root Repair material specifically has

been created as a white premixed cement for both permanent root canal repairs and apico retrofillings. As a
true bioceramic cement, the advantages of this new repair material are its high pH (pH >12.5), high resistance
to washout, no-shrinkage during setting, excellent biocompatibility, and superb physical properties. In fact, it
has a compressive strength of 5070MPa, which is similar to that of current root canal repair materials, ProRoot
MTA (DENTSPLY) and BioAggregate (Diadent). However,
a significant upgrade with this material is its particle
size, which allows the premixed material to be extruded
through a syringe rather than inconsistent mixing by
hand and then placement with a hand instrument.
The Clinicians Report (November 2011) published
findings on EndoSequence Root Repair Material. Some
of its noted advantages as a root repair material were:
_easier to use and place than previous similar products,
_good dispenser (tip/syringe) for easy dispensing,
_radiopaque,
_mulitple uses for a variety of clinical conditions,
_no mixing required.
Furthermore, their final conclusion was that 95
per cent of 19 CR Evaluators stated that they would
incorporate EndoSequence Root Repair Material into
their practice. Ninety-five percent rated it excellent or
good and worthy of trial by colleagues.
Another significant piece of research was published
in the Journal of Endodontics, where a research team
investigated the antibacterial activity of EndoSequence
Root Repair material against Enterococcus faecalis. The
aim of this study was to determine whether EndoSequence Root Repair material either in its putty form

Fig. 10a

Fig. 10b

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Fig. 9d

or as a syringeable paste possessed antibacterial properties against a collection of Enterococcus faecalis strains.
As a standard, they compared the ESRRM to MTA. Their
conclusion was, ESRRM, both putty and syringeable
forms and white ProRoot MTA demonstrated similar antibacterial efficacy against clinical strains ofE. faecalis.9
This research again validated earlier studies that
found ESRRM (Putty) and ESSRM (Paste) displayed similar in vitro biocompatiblity to MTA. Additionally, other
studies found that the ESRRM had cell viability similar to
Gray and White MTA in both set and fresh conditions.10
Even more significant research was published
(January 2012) concerning bioceramics in general. In
a comparison of endodontic sealers, it was demonstrated that in various moisture conditions within a
root canal, iRoot SP (EndoSequence BC Sealer) outperformed all the other sealers. The conclusion of
the study was, Within the experimental conditions
of this in vitrostudy, it can be concluded that the bond
strength of iRoot SP to root dentin was higher than
that of other sealers in all moisture conditions.11
As mentioned previously, the bioceramic material to
use in surgical cases is the EndoSequence Root Repair
Material (RRM). The ESRRM is available in two different
modes. There is a syringeable RRM (very similar to the
basic BC Sealer in its mode of delivery) and there is also
a RRM putty that is both stronger and malleable. The
consistency of the putty is similar to Cavit G. The RRM
in a syringe is obviously delivered by a syringe tip but the
technique associated with the putty is different.
When using the putty, simply remove a small
amount from the room temperature jar and knead it for

Fig. 10c

CE article _ bioceramic technology

a few seconds with a spatula or in your gloved hands.

Then start to roll it into a hotdog shape. This is very similar to creating similar shapes with desiccated ZOE or
SuperEBA (Bosworth). Once you have created an oblong
shape, you can pick up a section of it with a sterile instrument and use this to deliver it where needed (Fig. 8).
This is an easy technique for apico retro fills, perforation
repairs, and even for resorption defects. After placing
the putty into the apical preparation (or defect) simply
wipe with a moist cotton ball and finish the procedure.
The cases pictured in Figs. 9a to 10c are evidence of
how beautifully this technique works. These cases are so
significant because they clearly demonstrate the extraordinary healing capability of bioceramics, when used
as a repair material. The X-rays display amazing healing
and bone fill in less than six months, in the mandible.

_Pulp capping with bioceramics

One of the other significant benefits of having bioceramics come pre-mixed in a syringe (EndoSequence
Root Repair Material) is the ability for all dentists to
now easily treat young patients in need of pulp caps or
other pulpal therapies (e.g., pulpotomies). Previously,
many specialists considered MTA to be the ideal material for a direct pulp cap because it did not seem to engender a significant inflammatory response in the pulp.
Unfortunately, due to price concerns and the difficulty
of placement, this methodology was not universally
accepted. However, we now have a true bioceramic
material (ESRRM) that not only works well, but is easier to use. It is much easier. Hopefully, this will lead to an
increased use of bioceramics in our pediatric patients
and help these patients save their teeth. All dentists
can benefit from this upgrade in technique.
The technique itself for a direct pulp cap with the
bioceramic root repair material is as follows: Isolate the
tooth under a rubber dam and disinfect the exposure
site with a cotton ball and NaOCl. Apply a small amount
of the RRM from the syringe or, take a small amount
of the RRM putty from the jar, and place this over the
exposure area. Then, cover the bioceramic repair material with a compomer or glass ionomer restoration.
Following the placement of this material, proceed with
the final restoration, including etching if required.
Single visit direct pulp capping is now here.

_Future directions and prosthodontic

applications
The future promises to be even more exciting in the
world of bioceramics. There will be new fast set (8 to 10
minutes) repair materials introduced, as well as a special bioceramic putty for pediatric use (primary teeth).
We have also seen the melding of bioceramic technology into the world of prosthodontic cements, with the

introduction of Ceramir Crown & Bridge (Doxa Dental).

It is easy to predict that we will see more applications of
this technology in different aspects of dental medicine.
In this article, we have introduced a new bioceramic
sealer (EndoSequence BC Sealer) that when combined
with coated cones offers an exciting new obturation
technique (Synchronized Hydraulic Condensation). The
properties associated with the new bioceramic sealer
also allow us to be more conservative in our endodontic shaping which ultimately leads to the preservation
of natural tooth structure. Surgical applications have
also been introduced, and cases shown, which demonstrate the remarkable ability of bioceramics. The future
is bright for bioceramic technology and even more
exciting for dental medicine._
Editorial note: A complete list of references is available from
the publisher.

_about the authors

roots

Dr Ken Koch, received both his DMD and certificate in endodontics

from the University of Pennsylvania School of Dental Medicine. He is
the founder and past director of the New Program in Postdoctoral
Endodontics at the Harvard School of Dental Medicine. Prior to his
dndodontic career, Koch spent 10 years in the Air Force and held,
among various positions, that of chief of prosthodontics at Osan Air
Force Base and chief of prosthodontics at McGuire Air Force Base.
In addition to having maintained a private practice, limited to endodontics, Koch has lectured extensively in both the United States and abroad. He is also the
author of numerous articles on endodontics. Koch is a co-founder of Real World Endo.
Dr Dennis Brave, a diplomate of the American Board of Endodontics and a member of the College of Diplomates, received his
DDS degree from the Baltimore College of Dental Surgery, University of Maryland and his certificate in endodontics from the
University of Pennsylvania. In endodontic practice for over 25
years, he has lectured extensively throughout the world and
holds multiple patents, including the VisiFrame. Formerly an associate clinical professor at the University of Pennsylvania, Brave
currently holds a staff position at The Johns Hopkins Hospital. Along with having authored numerous articles on endodontics, Brave is a co-founder of Real World Endo.
Dr Allen Ali Nasseh, received his MMSc degree and Certificate
in Endodontics from the Harvard School of Dental Medicine in
1997. He received his DDS degree in 1994 from Northwestern
University Dental School. He maintains a private endodontic
practice in Boston (Microsurgicalendo.com) and holds a staff
position at the Harvards postdoctoral endodontic program.
Nasseh is the endodontic editor for several dental journals and
periodicals and serves as the Alumni Editor of the Harvard
Dental Bulletin. He serves as the Clinical Director of Real World Endo.
The authors may be contacted via thier website, www.RealWorldEndo.com, or via
email at info@realworldendo.com

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